Nov 13 Why We Need a Market for Kidneys

It’s estimated that your kidneys filter waste products from about thirty-five gallons of blood per day; it is this filtrate that makes urine, which is promptly removed from the body every few hours. Most people are unaware of the vital role that the kidney plays in bodily maintenance – that is, until something goes awry. It is currently estimated that 2.4 percent of the total adult population in the United States have End-Stage Renal Disease (ESRD) – for these approximately seven million people, their kidneys are functionally nonexistent.[1] As a result, their bodies begin to accumulate an alarming quantity of toxic waste products. If no interventions were taken, these patients would die in just a few days. Fortunately for them, hemodialysis – a medical process by which blood is filtered by a machine outside the body – is available.

While hemodialysis can, in essence, save lives, it comes at a tremendous cost. Due to the rapid rate at which the body accumulates these toxins, patients need to undergo dialysis treatments three times weekly, with very little room for missing an appointment. This places an undue stress on the lifestyle of these patients. According to a report from the United States Renal Data System (USRDS), upon initiating hemodialysis treatments the expected lifespan for a patient aged 40-44 is only eight years, and a patient aged 60-64 is expected to live for four and a half more years.[2]

Fortunately, a solution exists: a kidney transplant from either a living or deceased donor. Granted, with acute risks from surgery or transplant rejection, this solution is not perfect; however, a kidney transplant can free a patient from dialysis visits every other day, thus allowing them to return to a relatively normal life.

While kidney transplants are a marvel of modern medicine, the largest limiting factor is the number of kidneys available for transplant. While deceased-donor transplants – where after an otherwise healthy person’s death, the cadaveric organs are transplanted into the patient with ESRD – are becoming more common, there are still significant logistical limitations, legal considerations, and surgical complexities that will limit a dramatic increase in deceased-donor transplants. At the time of this writing, there are more than 116,000 patients on the waiting list for a kidney donation[3]; yet, in 2016, only 19,060 kidney transplants were performed. Of these, 13,431 were from a deceased-donor, and the rest – 5,629 – were from living donors.[4] It is estimated that twenty people die each day in the United States waiting for a kidney transplant; the average wait time for a kidney while on the transplant list is four and a half years.[5]

Currently, the only mechanism by which a living donor kidney transplant occurs is by a donor volunteering – completely out of altruism, without any material compensation. This is in fact legally rooted in the National Organ Transplantation Act of 1984, which makes it unlawful to receive any compensation for donating an organ.[6] I believe that this act greatly limits the availability of organs, and that by altering this law so that it would be legal to receive compensation for a kidney donation, thousands of patients with ESRD might survive.

I believe the main reason to legalize kidney donor compensation is to increase the supply of kidneys. As the list of patients on the kidney waiting list grows, America is in dire need of a solution. While growing organs in a lab may be a few years away[7], compensating otherwise healthy patients for their kidneys would immediately boost the supply. It’s straightforward economics: if you increase the amount something is worth, people will sell more of it. In this case, currently kidneys are selling for $0.00 (that is to say, free); if the price were increased to perhaps $45,000, would-be donors would be much more likely to consider donating, and then much more likely to actually donate. In this scenario, thousands on the waiting list would benefit immediately.

Even more than the medical advantage of shorter waiting times on the transplant list, compensating donors would save money, too. In a cost-benefit analysis from American Journal of Transplantation in 2016[8], Held et al. calculated that by paying $45,000 for a kidney donation, the net benefit to society would total $46 billion by reducing the actual monetary cost of dialysis and by improving the lives of those on dialysis. The authors of this study note that $45,000 per kidney is conservative; based on their model, compensation per kidney could be increased to $1,200,000 before there is no longer any net benefit.

Furthermore, compensating donors would eliminate the current organ trafficking market, and improve safety for those that would otherwise sell their organs illegally. A thriving black market currently exists for kidneys, and those who choose to sell their kidneys in such a way are often manipulated and cheated.[9] The World Health Organization estimates that approximately 10% of those in need of a transplant receive one, and approximately 10% of these patients do so via illegal means.[10] By legalizing this practice, the United States will move this hidden, dangerous, and exploitative market from the shadows, and into a more regulated, safe setting. Instead of seeking out illicit organ compensation, a would-be donor could safely get the compensation they so desire, all while protecting the health of donor and recipient alike.

This isn’t a new idea either: compensation for kidney transplants is already legal in Iran. In 1998, the government of Iran started compensating kidney donors as part of their Living Non-Related Donation program.[11] Just one year after the program was initiated, the number of transplants in Iran doubled, with 80% of these donations being from unrelated donors. While the program is not without its flaws as my colleague Alana points out, one of the main benefits seen from this program was a significant reduction in the time on the waiting list – a potential life saver for someone with ESRD.

The obvious counter to this argument is that the system is exploitative: if people will be paid ~$45,000 for a kidney, poorer individuals would be much more likely to donate; in fact, it has been argued that it would coerce those in lower economic classes into giving a kidney, despite the quite significant risks posed by surgery. However, Anthony Monaco, former president of the American Society of Transplant Surgeons, notes that, “developed societies have already become comfortable with the use of tangible recognition for personal self sacrifice that is most likely to flow to the needy. If military service can be recognised with inducements such as paid education, enlistment bonuses, and financial recovery for injury or mortality, why should the decision to donate an organ be viewed differently?” One possible solution to the exploitation issue is to have non-monetary compensation – perhaps compensate kidney donors with “priority health care” instead of dollars.[12] This would allay concerns about exploitation, while at the same time providing assurance to individuals who do give their kidneys that they would be protected from major health problems in the future.

Overall, end-stage renal disease remains one of society’s ills. While hemodialysis offers a semi-permanent solution, the associated lifestyle and cost make it untenable. Kidney transplantation provides a cost- and medically-effective procedure that essentially “cures” end-stage renal disease. That being said, the current state of kidney transplants is also untenable, with its extreme shortage of organs. By allowing donors to be compensated for their kidneys, not only will the availability of organs increase, thus serving to hasten the current wait time of approximately 4.5 years, but also to minimize the cost to society. The ever-present “black market” of organ transplantation could be severely limited, also. Lastly, concerns about this system being exploitative are grossly exaggerated, as the availability of simple pay-for-service schemes already exist in the form of military service. I think given its obvious benefits, it is imperative that we rapidly legalize a market for organs; for every day there is a shortage of kidneys, dozens of patients will die.

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